Failure to Provide Ordered Mounjaro for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a physician‑ordered diabetes medication, Mounjaro, to a resident over an extended period. The resident had diagnoses including diabetes mellitus, pain in the right knee, cognitive communication deficit, difficulty in walking, and dementia with moderate cognitive impairment documented by BIMS scores of eight on both admission and quarterly MDS assessments. The resident’s care plan identified diabetes and included an intervention that staff would administer medications as ordered. An order in the EMR directed that Mounjaro 2.5 mg/0.5 mL be injected every Monday morning for diabetes starting in August. Review of the Treatment Administration Record showed that, between early September and the end of January, staff administered only two of 22 scheduled Mounjaro doses, with two doses left blank and 18 doses marked as “Other/See Nurses Notes.” Multiple eMAR notes documented that Mounjaro was unavailable, on order, or awaiting delivery or clarification, and later entries repeatedly stated that the medication was unavailable. One note indicated the facility was awaiting clarification on Mounjaro without specifying what clarification was needed, and another documented that the NP was notified without stating what was communicated. During this same period, a physician progress note recorded a fasting blood sugar over 500 mg/dL and ordered an increase in Lantus and an endocrinology appointment, but did not address the ongoing Mounjaro order. Nursing staff interviews revealed that the nurse responsible for the resident’s medications understood that Mounjaro required prior authorization and that the pharmacy had indicated it would be covered once but would need prior authorization for subsequent fills. The nurse stated her usual practice was to place residents needing prior authorization into the provider’s folder and document this in the EMR, and to call the provider if a resident had not received a medication. However, the administrative nurse reported she had not received any reports that the resident was not receiving Mounjaro and had not seen any prior authorization request for it, despite expecting staff to notify her and the physician after one missed dose. The resident reported not receiving Mounjaro injections and expressed a desire to be on the medication. The facility’s Pharmacy Services Overview policy required that residents have a sufficient supply of prescribed medications and receive them in a timely manner, which was not met in this case.
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